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What is the most common time frame for spontaneous abortion to occur during pregnancy?
Which of the following is a major etiology of spontaneous abortion?
Which of these factors increases the risk of spontaneous abortion?
Which test is performed to assess for products of conception in the case of a suspected spontaneous abortion?
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What is indicated by a closed cervical os when assessing for spontaneous abortion?
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What symptom is NOT typically associated with spontaneous abortion?
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What is the management approach for a complete spontaneous abortion?
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What does a decrease in progesterone levels indicate in the context of spontaneous abortion?
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What is a common characteristic of threatened abortion?
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Which method is typically used for surgical evacuation in cases of spontaneous abortion?
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What symptom is NOT associated with septic abortion?
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Which of the following is considered a selected risk factor for intrauterine fetal demise?
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What happens to the fetal heart sounds in cases of intrauterine fetal demise?
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What is one of the purposes of administering Rh (D) immune globulin to Rh negative mothers?
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Which of the following treatments is utilized for managing complications of septic abortion?
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What is the most common outcome for a threatened abortion?
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What is the preferred management option for induction of labor after 24 weeks, even in cases where the baby is breech?
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Which test is used to diagnose fetomaternal hemorrhage?
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What is defined as three or more consecutive pregnancy losses?
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Which of the following is NOT included in the selected common testing for recurrent pregnancy loss?
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What is a key characteristic of cervical insufficiency?
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What does a second-trimester cervical length of less than 25mm indicate in the context of cervical insufficiency?
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What treatment methods are primarily used for managing cervical insufficiency?
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What is a potential complication of prolonged retention of a fetus after intrauterine fetal demise?
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Study Notes
Spontaneous Abortion
- Loss of a viable uterine pregnancy before 20 weeks
- Most common in the first trimester (before 12 weeks)
- Often identified by falling hCG levels or ultrasound findings
- Presents with vaginal bleeding and pelvic cramping
Spontaneous Abortion: Etiology
- Fetal chromosomal anomalies are found in about 70% of pregnancy losses
- Maternal anatomic anomalies, such as uterine fibroids, polyps, or septa, can also contribute
- Abnormal implantation, corpus luteum failure, TORCH infections, and trauma can also cause miscarriage
Spontaneous Abortion: Risk Factors
- Maternal age over 35 years
- Prior pregnancy loss
- Smoking and alcohol consumption
- Maternal diseases, including infections, diabetes, obesity, thyroid disorders, and thrombophilias
Spontaneous Abortion: Workup
- Pelvic exam to assess bleeding from the cervix and open cervical os
- Transvaginal ultrasound to assess for products of conception and fetal heartbeat
- Serial hCG and progesterone levels: hCG should increase by at least 60% over 48 hours, while low progesterone is associated with failed gestation or ectopic pregnancy
Complete Spontaneous Abortion
- Documented intrauterine pregnancy
- Bleeding and cramping
- Closed cervical os
- No products of conception (POC) evident
- No evidence of ectopic pregnancy
- Management is supportive, including antibiotics in some cases. Methylergonovine can be used to reduce retained tissue and infection risk.
Other Abortion Types
- Threatened Abortion: Bleeding and cramping with a closed cervical os and a viable pregnancy. May resolve or progress to spontaneous abortion.
- Inevitable Abortion: Bleeding and cramping with an open cervical os and a viable pregnancy. Requires surgical intervention.
- Incomplete Abortion: Bleeding and cramping with an open cervical os and no fetal heartbeat, partially expelled POC. Requires either surgery or medical management.
- Missed Abortion: Bleeding and cramping with a closed cervical os and no fetal heartbeat, retained POC.
Threatened Abortion
- Bleeding in early pregnancy (<20 weeks) with a closed cervical os and a viable pregnancy.
- May resolve or progress to spontaneous abortion.
- Weekly ultrasounds and serial hCGs until bleeding resolves.
- Increased risk of preterm labor or intrauterine growth restriction (IUGR).
- Common causes include implantation at the time of menses, cervical trauma during intercourse, and subchorionic hemorrhage.
Spontaneous Abortion (Inevitable, Incomplete, Missed)
- Surgical evacuation (dilation and suction curettage)
- Medical evacuation using mifepristone and misoprostol.
- Mifepristone is a progesterone antagonist that causes endometrial degeneration
- Misoprostol is a prostaglandin E1 analog that causes uterine contractions.
- Expectant management: allow natural passage of POC.
Septic Abortion
- Spontaneous abortion with intrauterine infection
- May occur with attempted self-abortion.
- Vaginal bleeding, pelvic cramping, fever, and foul-smelling discharge.
- Treated with broad-spectrum antibiotics and surgical evacuation with suction curettage.
- Increased risk of uterine perforation.
Spontaneous Abortion: Alloimmunization Prevention
- Rh negative mothers receive Rh (D) immune globulin.
Intrauterine Fetal Demise
- Pregnancy loss after 20 weeks
- Death before delivery.
- Mother may notice lack of fetal movement.
- Uterus may be small for gestational age.
- Absence of fetal heart sounds.
- Diagnosis: ultrasound showing absence of fetal heartbeat.
Intrauterine Fetal Demise: Selected Risk Factors
- Congenital anomalies
- Fetal growth restriction
- Maternal infection (systemic or in utero)
- Placental abruption
- Maternal chronic disease
- Cord accidents
- Drugs, especially crack cocaine
Intrauterine Fetal Demise: Management
- Before 24 weeks: dilation and evacuation (D&E)
- After 24 weeks: induction of labor (preferred route, even if baby is breech).
- May allow delay until the patient is ready.
- Prolonged retention of the fetus can cause disseminated intravascular coagulation (DIC).
Intrauterine Fetal Demise: Further Workup
- Fetal autopsy
- Placental examination
- Drug screen
- Fetal chromosome testing
- Testing for antiphospholipid syndrome
- Testing for fetomaternal hemorrhage
Fetomaternal Hemorrhage
- Bleeding without trauma or abruption
- Large hemorrhage can present as fetal death.
- Diagnosis: Kleihauer-Betke acid elution assay (detects fetal hemoglobin F in maternal circulation) or flow cytometry (using monoclonal antibody to hemoglobin F).
Recurrent Pregnancy Loss
- Three or more consecutive pregnancy losses
- Many potential causes.
Recurrent Pregnancy Loss: Selected Common Testing
- Uterine hysterosalpingography (fluoroscopy of uterus and fallopian tubes) or sonohysterography (ultrasound of uterus filled with saline contrast)
- Karyotype of parents
- Anticardiolipin antibodies and lupus anticoagulant
- TSH
Cervical Insufficiency
- Inability of the cervix to retain pregnancy in the second trimester.
- Recurrent second-trimester pregnancy losses.
- Mild symptoms with pregnancy loss (no significant bleeding, cramping, or contractions).
- Contrast with spontaneous abortion which often occurs before 20 weeks and is associated with cramping and contractions.
Cervical Insufficiency: Diagnostic Criteria
- Obstetric history: ≥2 consecutive second-trimester losses with no or mild symptoms.
- Ultrasound: Second trimester cervical length < 25mm plus prior loss or preterm delivery.
- Physical Exam: Dilated and effaced cervix in early pregnancy.
Cervical Insufficiency: Treatment
- Cerclage (cervical stabilization with stitching)
- Vaginal progesterone
- Avoid exercise during pregnancy.
Elective Abortion
- Legal and controversial
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Description
This quiz covers the essential aspects of spontaneous abortion, including its definition, etiology, risk factors, and workup procedures. Test your knowledge on the causes and clinical assessment associated with early pregnancy loss. Ideal for students and professionals in obstetrics and gynecology.
